HospitalInspections.org

Based on observation, document review, and interview, the facility failed to take measures to contain and/or prevent the transmission of a highly suspected contagious Coronavirus (COVID-19) and failed to follow their own policy. This practice increased the risk of exposure to COVID-19 for patients who were COVID-19 negative upon admission to the facility.

Observations made 12/3/2020 on the facility's Observation Telemetry Unit and Medical Surgical Unit where a combined total of 22 of the facility's 31 confirmed COVID-19 positive patients were, revealed the facility had no dedicated COVID-19 unit, and were not attempting to contain all COVID-19 positive patients to one section of the unit.

Observations on 12/03/2020 revealed 12 patients were assigned to the facilities "Observation Telemetry Unit," and of those 12 patients 10 were confirmed to be positive for COVID-19. A review of nursing assignments for that unit revealed only one Patient Care Technician (PCT) assigned to all patients on that unit. This required the PCT to cross over from confirmed COVID-19 positive patients to confirmed COVID-19 negative patients. Review of the nursing assignments also revealed 1 nurse was assigned to take care of both confirmed positive COVID-19 patients and confirmed COVID-19 negative patients. It was observed all staff donned and doffed the appropriate PPE when entering and exiting the patient's room.

An interview with staff # 8 on 12/03/20 around 10:20 a.m. revealed that patient care staff would be assigned to both COVID-19 positive and negative patients and there were no dedicated staff assignments to care for only COVID-19 patients.

Observations made on 12/03/2020 on the Medical-Surgical Unit revealed 12 confirmed COVID-19 positive patients out of the 34 patients on the unit. The COVID-19 positive patients were dispersed throughout the unit.

An interview conducted on 12/03/2020 around 10:30 a.m. with staff # 14 was questioned regarding staffing assignments. Staff # 14 stated that nurses on the Medical/Surgical Unit would be assigned to care for both COVID-19 positive and negative patients, there were no dedicated assignments for nurses to only be assigned COVID-19 positive patients.

A review of the facility's infection control plan for isolation/COVID-19 revealed the facility would follow the CDC recommendations related to COVID-19. A copy of this policy was requested from the facility but was never given to the surveyors.


A review of the CDC Guidelines for patients with suspected Coronavirus Disease (COVID-19) were as follows:

" ...Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings (Updated November 4, 2020).............As a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for known or suspected COVID-19 patients. Dedicated means that HCP are assigned to care only for these patients during their shift."

A review of the nurse staffing revealed adequate nursing staff to provide dedicated nurses to the COVID-19 positive patients and maintain the facility's ideal staff/patient ratio of 1:4.

An interview with staff # 2 revealed the facility used dedicated nursing staff to COVID-19 positive patients until August 2020. Staff # 2 stated the facility stopped dedicated staffing due to staff reporting dissatisfaction with having four isolation patients, and PPE fatigue. Staff # 2 stated the nurses stated they would rather only have 1 or 2 COVID-19 positive patients in their 1:4 assignment. Staff #2 stated they felt the change from dedicated staffing was necessary to retain nursing staff.